Problem-Based Clinical Cases Obstetrics and Gynecology Rotation Gyn Cases Updated December 2004 OB Cases Updated June 2005 By Dr. Manisha Patel Table of Contents Section I: General Gynecology Page 4. Breast Disorders..................................................................................................................................... 1 5. Contraception ......................................................................................................................................... 2 7. Dysmenorrhea........................................................................................................................................ 3 8. Dyspareunia ........................................................................................................................................... 5 9. Ectopic Pregnancy.................................................................................................................................. 8 10. Enlarged Uterus...................................................................................................................................... 9 19. Menorrhagia ......................................................................................................................................... 10 23. Pelvic Relaxation .................................................................................................................................. 12 25. Postmenopausal Bleeding.................................................................................................................... 12 26. Postmenopausal Pelvic Mass............................................................................................................... 13 30. Premenopausal Pelvic Mass ................................................................................................................ 15 31. Premenstrual Syndrome....................................................................................................................... 16 33. Prepubertal Pelvic Mass....................................................................................................................... 17 38. Rape Victim .......................................................................................................................................... 17 44. Sterilization........................................................................................................................................... 19 47. Urinary Incontinence............................................................................................................................. 20 49. Vaginal Discharge / Itching................................................................................................................... 21 50. Vulvar Lesions...................................................................................................................................... 22 51. Preventative Care and Routine Screening............................................................................................ 23 Section II: Endocrinology and Fertility 15. Hirsutism/Virilization ............................................................................................................................. 24 18. Menopause........................................................................................................................................... 24 28. Precocious Puberty .............................................................................................................................. 25 35. Primary Amenorrhea ............................................................................................................................ 27 36. Primary Infertility................................................................................................................................... 30 41. Secondary Amenorrhea........................................................................................................................ 32 42. Secondary Infertility .............................................................................................................................. 34 Section III: Gynecologic Oncology 2. Abnormal Pap Smear ........................................................................................................................... 35 22. Ovarian Cancer .................................................................................................................................... 38 46. Trophoblastic Disease .......................................................................................................................... 41 Section IV: Infectious Disease 40. Salpingitis ............................................................................................................................................. 44 43. Sexually Transmitted Diseases ............................................................................................................ 45 Section V: Prenatal Care 3. Anemia in Pregnancy ........................................................................................................................... 48 6. Discrepant Fundal Size ........................................................................................................................ 49 11. Fetal Demise ........................................................................................................................................ 51 13. First Trimester Bleeding ....................................................................................................................... 51 14. Glucose Intolerance In Pregnancy........................................................................................................ 54 16. Hypertension in Pregnancy................................................................................................................... 57 17. Isoimmunization.................................................................................................................................... 60 20. Multiple Gestation................................................................................................................................. 61 32. Prenatal Diagnosis ............................................................................................................................... 63 45. Third Trimester Bleeding ...................................................................................................................... 64 48. Urinary Tract Infection in Pregnancy .................................................................................................... 66 Section VI: Obstetrics 1. Abnormal Labor .................................................................................................................................... 67 12. Fetal Distress ....................................................................................................................................... 69 21. Operative Obstetrics............................................................................................................................. 71 24. Post Dates............................................................................................................................................ 72 27. Postpartum Hemorrhage ...................................................................................................................... 74 29. Premature Rupture of Membranes ....................................................................................................... 76 34. Preterm Labor....................................................................................................................................... 78 37. Puerperal Infection ............................................................................................................................... 79 39. Rectovaginal Fistula ............................................................................................................................. 80 OB/GYN Problem-Based Clinical Cases 1998 Section 1: General Gynecology Section I: General Gynecology 4. Breast Disorders: 49 year-old Jean, G3 P2 Ab1, presents at your office complaining of a left breast lump. Your examination confirms a right breast upper outer quadrant 3 cm discrete, nontender, cystic mass. DDX: 1. Fibrocystic DZ -Most Common Breast Disease -Tender with hyperplastic changes -due to decreased progesterone or increased estrogen -Get a mammogram to rule out cancer -FNA to help in diagnosis -Provera, Tamoxifen, Paclodel to treat, diuretic to decrease edema 2. Fibroadenoma -Most Common Benign Tumor -Well circumscribed and freely moveable -increased with pregnancy; regress with menopause -Treatment involves surgical excision -Usually found in females < 30 3. Intraductal papilloma -usually develops just before or during menopause -presents with bloody discharge -excisional biopsy of involved duct 4. Mammary duct ectasia (Comedomastitis, Plasma Cell Mastitis) -Common in 40’s -presents with nipple discharge -presents with pain and tenderness (due to dilation of the ducts ) -chronic intraductal and periductal inflammation 5. Galactocele -Ductal obstruction -milky thick discharge 6. Carcinoma - 90% ductal; 10% lobular (often bilateral) - Paget’s 3% arises in secretory dusts and skin of the areola - PM women have a greater chance of being hormone receptor + which is associates with a better prognosis - most important prognosticator is axillary